Table 1. Characteristics of the interventions
CDPM practitioner Theoretical training on:
- Motivational interviewing
training
- Function of the respiratory system
- Function of the cardiovascular system
- Diabetes
- Risk factors
- Existing CDPM services
Practical training:
Three-week mentoring in specialized CDPM services facilities.
Preliminary clinical The clinical evaluation of participants includes:
evaluation
 Anthropometric characteristics
 Medical history
 Medication
 Functions (respiratory, cardiovascular, endocrine, gastro-intestinal)
 Lifestyle habits and risk factors
 Patient’s preoccupations and objectives
 Previous interventions (nutrition, physical activity, respiratory,
smoking cessation),
 Recent changes (weight, alcohol consumption)
Disciplines involved in The interventions, based on a referral from a family physician or nurse, are
the intervention provided by professionals in the following disciplines:
 Clinical coordination
 Nursing
 Physical activity therapy
 Nutrition
 Respiratory therapy
 Smoking cessation therapy
Implemented The interventions implemented are:
interventions
 Self-management support
 Education on diseases (diabetes, COPD, asthma, cardiovascular)
 Education on risk factors (pre-diabetes, high blood pressure,
dyslipidemias, obesity, physical inactivity, smoking)
 Counseling on medication
 Motivational interviewing
 Education about nutrition
 Education about physical activity
 Counseling on smoking cessation
Tools and support Each intervention is supported by print and other material to ensure that patient
material engagement is maintained even between the interventions. These include
documents on:
 Chronic disease management
 Asthma, COPD









Diabetes
Cardiovascular
Metabolic syndrome
Hypo/hypertension
Tools for smoking cessation
Stress management
Blood pressure monitoring journal
Personal objectives journal
Physical activity journal
Communication & The CDPM practitioners in our study work within primary care settings which
coordination enhances communication with primary care physicians, nurses and staff. The
clinical coordinator ensures optimal communication and transition of care
between the project team, the primary care professionals and specialized
services. Special attention is given to the distinction of tasks fulfilled by project
CDPM practitioners and tasks fulfilled by primary care nurses.
Integration Prior to the implementation of interventions, a pre-implementation evaluation
is conducted to identify the needs for CDPM services and the contextual factors
of the participating PC clinics in the follow-up of CD patients. The preimplementation evaluation of the project promotes the sharing of a common
positive vision of an intervention that focuses on prevention, earlier support for
patients in the course of their disease, interprofessional collaboration, services
integration, motivational interviewing and self-management support.
Participating primary Participating primary care professional include:
care professionals
 Family physicians (63)
 Nurses (5)
Participating primary care settings:
 Four (4) clinics
 Four (4) family medicine groups
Participating Participating specialists include:
specialists
 Cardiologists
 Internal medicine specialists
 Endocrinologists
 Pneumologists